Biliary Diseases: Dr. Wu Yang Dept. Of Surgery The First Affiliated Hospital Of Zhengzhou University

Biliary

Diseases

Dr. Wu Yang Dept. of Surgery The First Affiliated Hospital of Zhengzhou University

Anatomy Extrahepatic biliary tree  The extrahepatic bile duct system consists of the hepatic ducts, common hepatic duct, gallbladder, cystic duct and common bile duct.  The left and right hepatic ducts join together after leaving the liver. The confluence forms the common hepatic duct.  The common hepatic duct is joined at an acute angle by the cystic duct to form the common bile duct.

Anatomy Extrahepatic biliary tree  The common bile duct is lateral to the common hepatic artery and anterior to the portal vein. The distal one-third of the common bile duct passes behind the pancreas to the ampulla of Vater, also called the papilla.  The sphincter of Oddi surrounds the common bile duct as it traverses the ampulla of Vater and controls bile flow.

Anatomy Gallbladder  The gallbladder is a pear-shaped organ adherent to the undersurface of the liver in a groove separating the right and left lobes.  The wall of the gallbladder is composed of smooth muscle and fibrous tissue.

Anatomy Gallbladder  Arterial supply : The gallbladder is supplied by the cystic artery, which is usually (95% of the time) a branch of the right hepatic artery that passes behind the cystic duct.  Venous return is via cystic veins to the portal vein and small veins that drain directly into the liver.

Physiology  Bile is produced by the liver and transported via the extrahepatic ducts to the gallbladder where it is concentrated and released in response to humoral and neural control.  Hepatic production of bile is under neural and humoral control. Approximately 600ml of bile are produced daily.

Physiology  Functions of the gallbladder include: (1)Storage of bile. (2)Concentration of bile. (3)Release of bile.

Diagnosis examination of the biliary disease  B-ultrasound is both sensitive and specific in detecting biliary diseases, such as gallstones, tumor, cystic lesion and obstructive jaundice, and its major advantages are that it is rapid, inexpensive, noninvasive and free risk. In the investigation of gallstones, the correct diagnosis rate is more than 95% in the gallbladder, 70% in the extrahepatic ducts and 60% in intrahepatic ducts. In the investigation of obstruction, the correct diagnosis rate is more than 90%.

Diagnosis examination of the biliary disease  Plain abdominal films demonstrate the 15% of gallstones that are radiopaque.  Oral cholecystography (OCG) is an alternative method for demonstrating biliary calculi in patients with an equivocal gallbladder sonogram. It is rarely used today.  Intravenous cholangiography (IVC) is no longer performed.

Diagnosis examination of the biliary disease  Percutaneous transhepatic cholangiography(PTC) is useful in evaluating a jaundiced patient. It can localize the site of the obstruction and also allows the placement of biliary drainage catheters.  Endoscopic retrograde cholangiopancreatography (ERCP) is useful in evaluating a patient with biliary disease. The procedure is both diagnostic and therapeutic.

Diagnosis examination of the biliary disease  Hepatobiliary iminodiacetic acid (HIDA) scan make use of a gamma-ray-emitting radioisotope (i.e. 99m Tc) attached to a variety of lidocaine analogs bound to iminodiacetic acid, which is excreted in the bile. This test is easy to perform and is a good method of confirming of biliary and hepatic lesions which is especially applicable to patients with jaundice.

Diagnosis examination of the biliary disease  CT and MRI can be applied for the same situations as B-US but provides little advantage and is more expensive.  Operative and postoperative direct cholangiography. This procedure is frequently performed in the operating room at the time of exploration of biliary tract.

Gallstone & Chronic Cholecystitis

Types of stones  Cholesterol stones is frequently single and light in weight. About 75% of all gallstones in China are the cholesterol type and 80% of which are in the gallbladder.  Pigment stones are black to dark brown. About 37% of all gallstones in China are the pigment type and 75% of which are in bile duct.  Mixed stones are usually brown and multiple. About 6% of all gallstones in China are the mixed type, 60% of which are in the

Symptoms and signs  Biliary colic, the most characteristic symptom, is caused by transient gallstone obstruction of the cystic duct. Nausea and vomiting may accompany the pain.  During an attack, there may be tenderness in the right upper quadrant, and rarely, the gallbladder is palpable.

Laboratory findings  An oral cholecystogram will usually show stones in the gallbladder. Ultrasound scans are as sensitive and specific as oral cholecystogram, and they may be used as an alternative method of diagnosing gallbladder stones.

Differential diagnosis  Duodenal ulcer  Pancreatitis  Myocardial infarction  Gastric tumors

Treatment  Surgical treatment, cholecystectomy, should be performed in most patients with symptoms.  Recently, as the technique of laparoscopic cholecystectomy has been widely spreaded, laparoscopic cholecystectomy is the best choice for most patients.

Treatment The decision whether to explore the duct at the time of cholecystectomy can be made according to the following:  The absolute indications are preoperative demonstration of stone by X-ray and ultrasound, preoperative history of cholangitis with jaundice, and a positive operative cholangiogram.

Treatment The decision whether to explore the duct at the time of cholecystectomy can be made according to the following:  The relative indications are mild jaundice without fever and chills, small stone, and a dilated duct.

Treatment  Other new methods are used to treat gallstone and chronic cholecystitis, such as, chemical cholecystectomy, extracorporeal shock wave lithotripsy (ESWL) and dissolving gallstone or taking off gallstone by percutaneous transhepatic paracentosis, the effection of which is not certainty.

Acute Cholecystitis

Acute cholecystitis  In 80% of cases, acute cholecystitis results from obstruction of the cystic duct by a gallstone.  About 20% of cases of acute cholecystitis occur in the absence of cholelithiasis. Some of these are due to cystic duct obstruction by another process such as a malignant tumor.

Symptoms and signs  The first symptom is abdominal pain in the upper quadrant, sometimes associated with referred pain in the region of the right scapula in 75% of cases.  Nausea and vomiting are present in about half patients, but the vomiting is rarely severe. Mild icterus occurs in 10% of cases. The temperature usually ranges from 38 to 38.5℃.

Symptoms and signs  Right upper quadrant tenderness is present, and about a third of patients the gallbladder is palpable.  If instructed to breath deeply during palpation in the right subcostal region, the patient experiences accentuated tenderness and sudden inspiratory arrest (Murphy’s sign).

Laboratory findings  The leukocyte count is usually elevated to 1215 thousand/uL.  A mild elevation of the serum bilirubin (in the range of 2-4mg/dL) is common.

Imaging studies  A plain X-ray of the abdomen may occasionally show an enlarged gallbladder shadow.  Ultrasound scans show gallstones, sludge, and thickening of the gallbladder wall.

Differential diagnosis  Acute peptic ulcer with or without perforation  Acute pancreatitis  Acute appendicitis  Acute viral hepatitis  Severe pneumonitis in the right lung or acute myocardial infarction

Complication  The major complications of acute cholecytitis are empyema, gangrene, and perforation.

Treatment  Intravenous fluids should be given to correct dehydration and electrolyte imbalance.  A nasogastric tube should be inserted.  Antibiotic should be given. These methods are suitable for preoperative patients and expectant management.

Treatment

 Cholecystectomy is the preferable operation in acute cholecystitis and can be safety performed in about 90% of patients.  There are two approaches to the timing of surgery:(1) Immediate surgery, that is, with in 72 hours of the onset of symptoms. (2) Delayed surgery, that is, after recovery from the acute attack with intravenous fluids and antibiotics. Surgery should be performed approximately 6 weeks after the acute inflammation has resolved.

Treatment  Operative cholangiography should be performed in most cases and the common bile duct explored if appropriate indications are present.

Cholangitis

Etiology  Bacterial infection of the biliary ducts.  The principal causes are choledocholithiasis ascariasis, biliary stricture, and neoplasm.  Less common cause are chronic pancreatitis, ampullary stenosis, duodenal diverticulum, congenital cyst, and parasitic invasion.

Clinical findings  The symptoms of cholangitis (sometimes referred to as Charcot’s triad) are biliary colic, jaundice, and chills and fever. Although a complete triad is present in only 70% of cases.  Laboratory findings include leukocytosis and elevated serum bilirubin and alkaline phosphatase levels.

Clinical findings  Early in an attack, an ultrasound scan will often give useful diagnostic information. Further work-up (PTC, ERCP etc.) can proceed later after the acute manifestations are brought under control.  Direct cholangiography is dangerous during active cholangitis.

Clinical findings  The term acute obstructive supperative cholangitis (AOSC) has been used for most severe form of this disease, which usually occurs in complete obstruction of biliary ducts.  Now in China, AOSC has been replaced with acute cholangitis of severe type (ACST).  The diagnosis pentad of ACST consists of abdominal pain, jaundice, high fever and chills, mental confusion or lethargy, and

Treatment  Most cases of cholangitis can be controlled with intravenous antibiotic which include the drugs of anti-anaerobes.

Treatment  For patients with severe cholangitis, the bile duct must be promptly decompressed. In most instances. Laparotomy and common duct exploration are required.

Treatment  Cholangitis accompanying neoplastic obstruction may be managed by insertion of a transhepatic drainage catheter into the bile duct, percutaneous transhepatic cholangiodrainage (PTCD).

Treatment  If the patients condition is precarious during laparotomy, the septic process can be halted by inserting a decompressing T tube and concluding the procedure. A second operation will then be necessary when the patient has recovered.

Choledocholithiasis

Clinical findings Symptoms  Choledocholithiasis may be asymptomatic or may produce sudden toxic cholangitis, leading to a rapid demise.  Biliary colic, jaundice or pancreatitis may be isolated findings or may occur any combination along with signs of infection (cholangitis).

Clinical findings Symptoms  Choledocholithiasis should be strongly suspected if intermittent chills, fever, or jaundice accompany biliary colic.  Light stools may be reported.  Pruritus is usually the result of persistent longstanding obstruction.

Clinical findings Signs  The patient may be icteric and toxic, with high fever and chills.  A palpable gallbladder is usually in patient with obstructive jaundice.  Tenderness may be present in the right upper quadrant.  Tender hepatic enlargment may occur, especially if obstruction has been present for more than several days.

Clinical findings Laboratory finding  In cholangitis, leukocytosis of 15000/ul is usually present.  A rise in serum bilirubin often appears within 24 hours of the onset of symptoms.  The serum alkaline phosphatase levels usually rise and may be the only chemical abnormalities in patients without jaundice.

X-ray findings  Radiopaque gallstones may be seen on plain abdominal films.  Ultrasound scans usually show gallbladder stones and, depending on the degree of obstruction, dilatation of the bile duct.  In puzzling cases, ERCP or PTC may be indicated.

Complications  Multiple intrahepatic abscess.  Hepatic failure or secondary biliary cirrhosis may develop in unrelieved obstruction of long duration.  Acute pancreatitis.  Gallstone ileus.

Treatment  Patients with acute cholangitis should be treated with systemic antibiotics, this usually controls the attack within 24-48 hours.  If the patient’s condition worsens within 2-4 days, laparotomy and exploration of the common bile duct should be performed.

Treatment  Patients with common duct stones who have had a previous cholecystectomy are best treated by endoscopic sphincterotomy.  Endoscopic sphincterotomy is unlikely to be successful in patients with large (>2cm) stones. Laparotomy and common duct exploration are required.

Treatment  If the patient still has a gallbladder, cholecystectomy and common duct exploration are indicated.

Treatment  After exploration of the duct is completed and all stones have been removed, the inside of the duct is inspected through the choledochoscope and a T tube is inserted.

Treatment  About two week after the operation, a postoperative cholangiogram should be performed through the T tube. If the duct is clear, the tube should be clamped overnight to make certain that the ductal system is functional. If no symptoms appear, the tube can be pulled out.

Treatment  There is a variety of methods to treat retained stones found on postoperative T tube cholangiograms.  For persistent stones, the easiest treatment is through the T tube and extract the stone with fiberoptic choledochoscope.

Intrahepatic duct stones

Clinical findings  Besides the symptoms resulting in extrahepatic duct stones, there are some specialties in symptoms of intrahepatic duct stone, such as persistent distending pain in liver area, chest and back, chills and fever, jaundice occuring both right and left intrahepatic duct obstruction.  Tender hepatic enlargement may often occur, and with marked tenderness, there are percussion pain in affected liver area.

Clinical findings  Ultrasound scans and CT scans usually show intrahepatic duct stones and, depending on the degree of obstruction, dilatation of the bile duct.  PTC and ERCP are most important examinal methods for diagnosis of intrahepatic duct stones .

Treatment  The treatment of intrahepatic duct stones is very complex, including operation, lithotrity dissolving stones, taking off stone by choledochoscope, traditional medicine therapy and so on.  The operations include cutting high biliary duct and taking off stones, intra-drainage.

Carcinoma of the gallbladder

Clinical findings Symptoms and signs  Right upper quadrant pain similar to biliary colic.  Obstruction of the cystic duct by tumor sometimes initiates an attack of acute cholecystitis.  Some cases present with obstructive jaundice .

Clinical findings Symptoms and signs  A palpable gallbladder would be an unusual finding with choledocholithiasis alone and should suggest gallbladder carcinoma .

Laboratory findings  Oral cholecystograms.  CT and ultrasound scans.

♥ The correct diagnosis has been preoperatively in only 10% of cases.

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Treatment  If localized carcinoma of the gallbladder is recognized at laparotomy, cholecystectomy should be performed along with wedge resection of an adjacent 3-5 cm of normal liver and dissection of the lymph nodes in the hepatoduodenal ligament.  In the few cases where cancer has not penetrated the muscularis mucosa, cholecystectomy alone should suffice.

Prognosis  Radiotherapy and chemotherapy are not effective palliative measures.  About 90% of patients are dead within a year after diagnosis.

Malignant tumors of the bile duct

Clinical findings Symptoms and signs  The illness presents with gradual onset of jaundice or pruritus.  Bilirubinuria is present from the start, and light-colored stools are usual.  Anorexia and weight loss develop with time.

Clinical findings Symptoms and signs  Icterus is the most obvious physical finding.  Hepatomegaly is common.  If the tumor is confined to the common duct, the gallbladder may distend and become palpable in the right upper quadrant.

Laboratory findings  The serum bilirubin is usually over 15 mg/dL.  Serum alkaline phosphatase is increased.  Fever and leukocytosis are not common.

X-ray findings  Ultrasound or CT scans usually detect dilated intrahepatic bile ducts.  PTC or ERCP early depicts the lesions and is indicated in all cases.

Treatment  Tumors of the distal common duct should be treated by radical pancreaticoduodenectomy (Whipple procedure) if it appears that all tumor could be removed.

Treatment  Mid common duct or low hepatic duct tumors should also be removed if possible, if the tumor cannot be excised, bile flow should be reestablished into the intestine by a cholecystojejunostomy or Roux-en-Y cholecystojejunostomy.

Treatment  Tumors at the hilum of the liver should be resected if possible and a Roux-en-Y hepatijejunostomy performed.

Prognosis  The average patient with adenocarcinoma of the bile duct survives less than a year. The overall 5-year survival rate is 15%.

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